Practice and associated factors of traditional uvulectomy among caregivers having children less than 5 years old in South Gondar Zone, Amhara Region, Ethiopia, 2020

Introduction Traditional uvulectomy is widely practiced in Africa especially in sub-Saharan countries including Ethiopia. Studies conducted in different times and areas of the world have shown that the level of practice of uvulectomy and its associated factors were varied from country to country. Therefore, this study was carried out to assess the practice and associated factors of traditional uvulectomy among caregivers having children less than 5 years old in the South Gondar Zone. Objective This study aimed to assess practice and associated factors of traditional uvulectomy among caregivers having children less than 5 years old in South Gondar Zone, Amhara Region, Ethiopia, 2020. Method A community–based cross-sectional study was conducted on 634 participants who were selected using a multistage with a simple random sampling method. Data were collected using a structured interviewer-administered Amharic version questionnaire; it was entered into Epi Data and analyzed using SPSS. Descriptive statistics were calculated and logistic regressions were fitted to declare statistical significance at p-value < 0.05 and 95% CI. Result The prevalence of traditional uvulectomy in this study was 52.5% (95% CI, 48.6–56.3%). Moreover, lack of information [AOR = 2.975 (1.677–5.277)], perceived as uvula causes illness [AOR = 4.888 (2.954–8.086)], future intention or will perform [AOR = 4.188 (2.584–6.788)], perceived as traditional uvulectomy should not be eradicated [AOR = 1.893 (1.172–3.057)]), saw the previous good result [AOR = 9.396 (5.512–16.016)], health personnel hospitality problem [AOR = 5.922 (2.392–14.664)] and did not get cured by pharmacologic treatment [AOR = 3.918 (2.073, 7.405)] were significantly associated with traditional uvulectomy. Conclusion and recommendation The prevalence of traditional uvulectomy was high. Lack of information, perceived as uvula causes illness, future intention to uvulectomy, perceived as traditional uvulectomy should not be eradicated, saw the previous good result, health personnel hospitality problem and did not get cured by pharmacologic treatment were the factors significantly associated with traditional uvula cutting. Therefore, special attention will be given to creating further awareness to the community at large and setting controlling mechanisms for the health care delivery system.


Conclusion and recommendation
The prevalence of traditional uvulectomy was high. Lack of information, perceived as uvula causes illness, future intention to uvulectomy, perceived as traditional uvulectomy should not be eradicated, saw the previous good result, health personnel hospitality problem and did not get cured by pharmacologic treatment were the factors significantly associated with traditional uvula cutting. Therefore, special attention will be given to creating further awareness to the community at large and setting controlling mechanisms for the health care delivery system.

Background
Uvulectomy is the entire or partial removal of the uvula through surgery, and the procedure can be viewed in two ways [1,2]. As a scientific treatment option to address conditions, for example, obstructive sleep apnea and hereditary angioneurotic edema [3,4]. The second view is as part of traditional and cultural medicine due to the attitude to prevent and treat various diseases as well as considered a ritual. The traditional view can cause serious side effects, which can lead to death in children [5,6].
Traditional uvulectomy is a surgical procedure in which the total or partial part of the uvula is removed by traditional surgeons. The uvula is a small pendant fleshy lobe that is located above the throat, hangs from the palate at a lower central border, and between the two lymphoid tissues or tonsils. Uvula helps to prevent choking, during swallowing by moving superiorly and close to the nasopharynx keep swallowed matter like food and liquid get into the nasal cavity [7][8][9]. There is a hypothesis suggesting that the uvula has some glandular tissue (glands) indicating that it can produce saliva which moistens the throat. It has a function in speech as well, used to articulate consonant sounds [3,10,11].
Traditional instruments such as a sharp blade (knife) and threads made from horsetail and other inputs are used for the cutting of uvula. First, the baby is held firmly and then the tongue is pulled. The uvula is then strapped by a thread, and cut out with a sharp instrument prepared by a traditional surgeon. The tools used to cut uvula are not clean and the procedure is careless, the individual who is subject to the practice is more likely to be exposed to a variety of health problems including death. As noted by various studies, hemorrhage following the procedure, nasal regurgitation, adjacent body part trauma (soft palate and tongue base abrasion), swallowing difficulty, malnutrition, speech problem, and local infections like abscesses, otitis media were the most prevalent complications [12][13][14][15]. And also systemic complications had been reported like septicemia, tetanus, hepatitis, HIV, and severe anemia [16][17][18][19].
Traditional uvulectomy was seen in various African countries, such as Kenya, Niger, Tanzania, Nigeria, Sudan, Eritrea, and Ethiopia [6,20,21]. The reasons for practicing this cultural treatment vary from country to country, and studies in different African countries at different times showed that parents and traditional surgeons were assumed uvula cause to several throat disorders and therefore, they believed it should be cut and removed [11,22]. From a community-based cross-sectional study done in Merawi town, Amhara region of Ethiopia reported that educational status, occupation, and the previous good result were the factors associated with the practice of traditional uvulectomy [23]. A qualitative investigation in Dadar, Oromia region of Ethiopia revealed that cultural influences, presence of traditional professionals in the area, family and peer pressure, lack of knowledge, and distance from health facilities were the main reasons for uvulectomy [24].
As parents and traditional surgeons affirmed, fear of the upper respiratory tract obstruction by large uvula and that the children will be leading to death is the main reason to undergo the procedure [5,11]. Children were the most vulnerable because consent was determined by the parents' believe (viewpoint) and the benefit of the surgeon, not the child's will [3,6]. In addition, researchers had pointed out that uvula was seen as the source of throat problems in childhood end up with vomiting, feeding difficulty, and hoarseness [13,22].
Although the age at which uvula cutting varies from country to country, it was most commonly seen in children under 5 years old and the peak age of the practice was in children 0-12 months [14,16,17]. In Ethiopia, 83.5% of uvulectomy was performed under 6 months of age [19].
To tackle traditional uvulectomy and the related complication, Ethiopia launched a national strategy and plan to eradicate (end) every harmful traditional practice including traditional uvulectomy by 2025 [25]. Great efforts have been done to achieve the national plans; such as health education about the negative consequences, community mobilization, and awareness creation to social help like "idir" leaders, religious leaders, and traditional healers to draw clients enhancing the capacity of service provision [25][26][27].
Despite the above efforts to reduce the problem over the years, findings from studies in different regions of Ethiopia show that the practice is still continuous and as many of the study participants reported that the victims were vulnerable to various health conditions. If the current situation (the practice of uvulectomy) is continuous, it will be impossible to accomplish the national plan or expectation of ending (eradicating) every traditional harmful practice from Ethiopia by 2025.
To comprehend a traditional practice of uvulectomy and achieve national expectations, localized and contextualized understanding of the practices and associated factors is crucial. Therefore, we conducted a community-based cross-sectional study to assess the practice and associated factors (identify determinants) of traditional uvulectomy among caregivers having children less than 5 years old in South Gondar Zone Amhara Region and to plan specific interventions to avoid traditional uvula cutting.

Study design, period, and area
A community-based cross-sectional study was conducted from March 1 to March 31, 2020, in South Gondar Zone, which is one of the Zones in the Amhara Region of Ethiopia and bordered on the South by East Gojjam, on the Southwest by West Gojjam and Bahir Dar, on the West by Lake Tana, on the North by Central Gondar, on the Northeast by Wag Hemra, on the East by North Wollo, and on the Southeast by South Wollo. The Zone is comprised of 13 woredas (Andabet, Dera, Ebenate, Estie, Farta, Fogera, Gunabegemider, Libokemkem, Lay Gayenet, Mena Meketewa, Sedie Muja, Simada, and Tachegayenet) and two administrative towns (Debre Tabor and Woreta), the capital of which is Debre Tabor, 666 km Southwest of Addis Ababa, the capital city of Ethiopia and 103 km Southeast of Bahir Dar, the capital city of Amhara Region. The total area of the Zone is 14,095.19 square kilometers and according to the 2007 census, the total population was 2,051,738, from which 1,041,061 were males and 1,010,677 females [28]. From the total population of 277, 887 were under-five children with 2:1 male to female ratio. Among the total population, 96.14 percent of the population was Orthodox religious and 3.68 percent were Muslim. The zone has one general hospital, seven district hospitals, and 93 health centers.

Population
All caregivers who had children less than 5 years old in South Gondar Zone were the source population of this study. However, caregivers who had less than five years of old children live in selected kebeles were the study population of this study.

Inclusion and exclusion criteria
Caregivers with children under five years of age who provided information and were available at the time of data collection were included in the study. Whereas, caregivers who were seriously ill at the time of data collection were excluded from the study.

Sample size determination
The sample size was calculated by using a software (EPI info version 7.2.1.0) considering the assumption of a 95% confidence interval, 5% degree of precision, 80% power, unexposed to the exposed ratio of 1:1, 10% non-response rate and design effect of 2 (Table 1). Finally, the sample size was 634.

Sampling procedure
A multi-stage sampling technique was used to select the study participants. First, by using the lottery method six woredas were selected, and based on the total number of caregivers having children less than five years in each district the study sample proportional allocation was made. After that, of the six districts, the recruited kebeles (small administrative units) were selected by the lottery method and proportional allocation of sample for the selected kebeles was made. In addition, "Gotes" from the recruited kebeles were selected with simple random sampling. Finally, the study subject or participant caregivers were selected in each chosen "Gotes" by using a sampling frame which was obtained from the local health extension workers (Fig 1).

Operational definitions
Knowledge: those caregivers who scored the mean or above for knowledge assessment questions were grouped as good knowledge and those caregivers who scored below the mean for knowledge assessment questions were grouped as poor knowledge.
Practice: this was measured from the report of caregivers and was coded 1 if caregivers reported that had performed traditional uvulectomy on their children; otherwise, it was coded 0. Attitude: related issues of the respondent were assessed by five yes or no questions focusing on the perception about uvula, harmfulness of traditional uvulectomy, future intention, encouraging others to perform uvulectomy on their children, and the eradication of traditional uvulectomy. It was measured separately from the report of caregivers and coded 1 if the caregivers reported yes; otherwise, it was coded 0.
Traditional uvulectomy: surgical removal of the uvula by traditional practitioners.

Ethical considerations
Ethical clearance was obtained from the ethical review committee of the School of Nursing on behalf of the institutional review board of the University of Gondar with Ref.No.; -S/N/2012/ 06/2012. Further permission and a supportive letter were obtained from zonal administrative, districts, and local (kebele) administrative. Ethical considerations were taken into account throughout the study. Voluntariness was asked and participants were informed as their participation is voluntary and that they can withdraw at any time of the study. In addition, the objective of the study was verified by the participants. They were informed about the confidentiality of the data being collected and oral consents were obtained. Data was collected by excluding names or any other personal identifiers from data collection tools. Moreover, the identifier for each eligible subject was replaced by a code. At the end of the interview, participants were informed about traditional uvula cutting and related issues.

Data collection tools and procedures
Data collection tool: a structured questionnaire containing socio-demographic background, questions about traditional uvulectomy knowledge, practice, and attitude as well as associated factors which were adapted from various works of literature previously done on similar topics [13, 15-17, 19, 22, 29, 30]. The questionnaire was first prepared in English and then translated to the local language (Amharic). Data collection procedure: the data was collected by two trained health extension workers from caregivers who have children less than 5 years old using an intervieweradministered questionnaire. Study participants having two under-five children were included with their younger children. And also, the data collection process was supervised by one clinical nurse. Instead of personal identifier code for each study participants were given. Data were checked and cleaned daily for completeness and consistency during data collection.

Data quality control
To ensure the quality of data, intensive training was given for 1 day before the data collection procedure starts to data collectors and supervisors about data collection processes and techniques. Local language-translated tools were used. A pre-test was conducted on 32 eligible caregivers (5% of sample size) at Andabet woreda Jaragedo and Semete kebele and that was not included in the study and tool modification was made by adding a variable health personnel hospitality problem. Moreover, the data collection process was supervised strictly.

Data processing and analysis
Data were entered and edited using Epi-Data by the principal investigator and then exported into SPSS version 23 for analysis. Descriptive measures of statistics like the frequency with percentage, mean with standard deviation, and median with interquartile range was used to describe the socio-demographic characteristics and the practice of traditional uvulectomy. Logistic regression (both bivariable and multivariable) was performed to identify the factors associated with traditional uvula cutting. Variables with a p-value < 0.2 in the binary regression analysis were entered for multivariable analysis and variables that had p-value < 0.05 in final model were reported as associated factors with adjusted odds ratio (AOR) and 95% CI. To check the model goodness of fit Hosmer and Lemeshow test was used.

Socio-demographic characteristics
In this study, a total of 634 caregivers who had children less than five years were included with a response rate of 100%. The mean age of participant caregivers was 28.78 years (SD = ± 4.352). The median (IQR) age of children was 16 (9 to 25) months. The majority of the respondents, 605 (95.4%) were Orthodox religious followers. Nearly all the caregivers, 604 (95.3%) were married. Regarding occupational status about 354 (55.8%) of respondents were farmers. About educational status, 335 (52.8%) could not read and write. The majority of the respondent's family monthly income was in between 2131-3560 ETB ( Table 2).

Knowledge about traditional uvula cutting and related issues
Out of the 634 respondents, 431 (68%) had information about traditional uvulectomy, but the overall participants who had good knowledge were 392 (61.8%). The major sources of information were family members 410 (64.7%) and neighbors 400 (63.1%), ( Table 3).

The practice of traditional uvulectomy in the South Gondar zone
The result of the study showed that about 333 (52.5%) (95% CI = 48.6-56.3%) caregivers practiced traditional uvula cutting to their children for having less than five years old (Fig 2). The median (IQR) age of uvula cutting was 5 (1/2 to 9) months. Among those children subject to traditional uvula cutting 39 (11.71%) faced complications following the procedure and the complication were adjusted organ damage such as throat and teeth (Table 4).

Attitude related issues about uvulectomy
The majority, 410 (64.7%) of the study participant had perceived as uvula causes illness and 365 (57.6%) of the study subject perceived as traditional uvula cutting is not harmful. And also 408 (64.4%) of the study participant believed that traditional uvula cutting should not be eradicated and the main reason was it is effective 375 (59.1%), (Table 5).

Reasons to practice traditional uvulectomy
The main reasons to subject their child for traditional uvula cutting were to treat illness (sore throat and difficulty of swallowing as well as recurrent infection), perceived as not able to cure

Factors associated with traditional uvula cutting
In bivariate analysis; child age, caregiver occupational status, family monthly income, poor knowledge (no information about traditional uvulectomy and related issues), perceived as uvula causes illness, perceived as an ultimate treatment option, future intention (will perform traditional uvula cutting), encourage others to practice uvula cutting, perceived as traditional uvula cutting is not harmful, perceived as traditional uvulectomy should not be eradicated, saw the previous good result, didn't get cured by pharmacologic treatment and health personnel hospitality problem were statistically associated with traditional uvulectomy with p-value <0.05 at 95% C.I. (Table 6). After bivariable analysis, those variables with p-value <0.2 were entered for further multivariable analysis. After adjusting for potential confounders in multivariable logistic regression analysis; no information about traditional uvula cutting and related issues, perceived as uvula causes illness, future intention (will perform traditional uvula cutting), perceived as traditional uvulectomy should not be eradicated, saw the previous good result, health personnel hospitality problem and didn't get cured by pharmacologic treatment were significantly related with traditional uvulectomy. But child age, caregiver's educational status, caregivers' occupational status, family monthly income, and perceived as traditional uvulectomy is not harmful weren't significantly associated with traditional uvulectomy in multivariable analysis.
Caregivers who had no information about traditional uvulectomy and related issues were 2.975 times more likely to practice traditional uvulectomy in their children than those who Similarly, future intention (will perform) was significantly associated with traditional uvulectomy. Caregivers who claimed to perform traditional uvula cutting in the future were 4.188 times more likely to practice uvula cutting traditionally [AOR = 4.188 (p < 0.001, 2.584-6.788)] than those who not intended to practice in the future.
Caregivers who perceived as traditional uvulectomy should not be eradicated were 1.893 more likely to practice traditionally uvulectomy on their children than those who perceived as it should be eradicated [AOR = 1.893 (p = 0.009, 1.172-3.057)].
Those caregivers who saw the previous good result practiced traditional uvulectomy on their children 9.396 times than those who didn't see previous good results [AOR = 9.396 (p < 0.001, 5.512-16.016)].
There was a strong association also between complaints of health personnel hospitality problems and practice of traditional uvulectomy on children. As a result, caregivers who complained of health personnel hospitality problems were 5.922 more likely to practice uvulectomy on their child than those who didn't complain about health personnel hospitality problems [AOR = 5.922 (p < 0.001, 2.392-14.664)].
Regarding therapeutic response, caregivers who claimed didn't get cured by pharmacologic treatment practices traditional uvulectomy on their children 3.918 times than caregivers not claimed didn't get cured by pharmacologic treatment [AOR = 3.918 (p < 0.001, 2.073-7.405)].  Table 6. Bivariable and multivariable logistic regression analysis of factors associated with traditional uvulectomy among caregivers having children less than 5 years old in South Gondar Zone, Amhara Region, Ethiopia, 2020 (N = 634).

Variables
Traditional uvulectomy

Discussion
In this study, we aimed to assess the practice of traditional uvulectomy and its associated factors among caregivers having children less than 5 years old in the South Gondar zone, Amhara Region, Ethiopia. Consequently, the practice of traditional uvulectomy was found to be 52.2% (95% CI: 48.6-56.3%) and lack of information, perceived as uvula causes illness, future intention, perceived as uvulectomy should not be eradicated, saw the previous good result, health personnel hospitality problem and didn't get cured by pharmacologic treatment were the factors significantly associated with traditional uvulectomy. The prevalence of uvulectomy in this study was lower than in a study conducted in Plateau State (Jos) and Jigawa State Nigeria which was practiced by 86.1% and 90% of the respondents, respectively [13,16]. The difference might be cultural disparities between the studies in Nigeria uvulectomy which was considered as religious dictates and making ritual as well as naming ceremony.
In addition, this was lower than a study conducted in Axum (which ranges from 72.8% to 86.9%) and in Fentale Woreda 84.7% [14,29,31]. The variation might be because of the time gap between the studies and it may improve awareness about scientific treatment options of uvulitis as well as increase the accessibility of health care services. But it was higher when compared to a research done in Debre Birhan Town (23.7%) and Merawi town (20%) [23]. This difference might be because of the variation of the study settings. In this study, participants were residing in the rural area as a result of less access to the health facility and sources of information like social media; on the contrary easily accessible to traditional surgeons.
In this study, the main reasons to perform traditional uvulectomy mentioned by caregivers were to treat illness (sore throat and difficulty of swallowing as well as recurrent infection) (45.9%), perceived as not able to cure by drugs (35.6%), and a previous good result (34.9%).
On the contrary to this study, a study carried out in Nigeria, suggested that a majority of participants(65.5%) did not know why they have undergone uvulectomy [13]. This variation might be due to the difference of study population and methodology, in which the respondents of the previous study were the individuals with amputated uvula in the age range of 2 to 53 years old and conducted by direct examination of the participant for presence or absence of their uvula (observational study). As a result, they may not remember what was the indication for the procedure being performed on them or did not know the indication since practiced on their childhood age by the consent of parents or caregivers.
The reasons affirmed by this study were different in Axum where the main reason was the early prevention of swelling (68.5%) [14,29]. This might be because of awareness of caregivers towards the treatment option of uvulitis has been improved as a result they may first attempt scientific treatment. Adjusting for other factors, lack of information was significantly associated with traditional uvulectomy practice. Caregivers who had no information about traditional uvula cutting and related issues were 2.975 times more likely to practice traditional uvulectomy in their children than those who have information about traditional uvulectomy and related issues. This is true that as awareness about available treatment options and the negative effect of traditional uvulectomy improved, the tendency towards seeking scientific treatment be increased.
Caregivers' attitudes-related concerns were other pushing factors to practice traditional uvulectomy. In this study, among the total respondents, 410 (64.7%) caregivers perceived as uvula causes illness was found to be significantly associated with traditional uvula cutting. Those caregivers who were perceived as uvula causes illness were 4.888 times to subject their child for traditional uvulectomy than those who were perceived as not causing illness. This is nearly consistent with a previous study done in central rural Tanzania where 90.3% of the respondents believed that long uvula (uncut uvula) causes illness (prolonged cough and fever) [32]. This is true that attitude undermined the practice as a result if a caregiver perceived as uvula causes illness, they are more adduce to practice uvulectomy.
Caregivers perceived as traditional uvulectomy should not be eradicated (since effective) was another factor significantly related to uvulectomy. In this study, 408 (64.4%) of participants perceived as traditional uvulectomy should not be eradicated (because it is effective = 308 (75.49%). Adjusting for other factors, those caregivers who perceived as traditional uvula cutting should not be eradicated were 1.893 more likely to practice traditional uvulectomy on their children than those who perceived as it should be eradicated. This was in agreement with a study done at the Congolese refugee camp in Tanzania where uvulectomy is beneficial and effective than modern medicine [33]. Negative attitudes undermined the healthcare-seeking behavior and pull to practice what they perceived as a result if the caregivers perceived that traditional uvulectomy is effective, they are more likely to practice it.
Future intention (will perform) was also significantly associated with traditional uvulectomy. Caregivers who claimed to perform traditional uvula cutting in the future were 4.188 times more likely to practice traditional uvulectomy than those who did not intend to practice in the future. This is true that a volition that intends to carry out is a driving force to attempt it.
Those caregivers who saw previous good results practiced uvula cutting on their children 9.396 times than those who didn't see previous good results. This study is similar to a study conducted in the Merawi Amhara region, Ethiopia, where previous good outcomes [23]. This could be based on if caregivers saw the good result from the previous uvulectomy procedure; they accept it as an effective and an alternative option and are more likely to practice it.
Another factor pointed out by this study that affects uvulectomy was health personnel hospitality problems. Among caregivers who subject their child to uvulectomy, 74 (11.7%) participants complained health personnel hospitality problem was the pushing factor. Moreover, caregivers who complained of health personnel hospitality problems were 5.922 more likely to practice uvulectomy on their child than those who didn't complain of health personnel hospitality problems. This was in line and nearly similar to reasons mentioned in a study carried out in Axum in which a lack of better medical care as a pushing factor was stated by 12.8% of respondents [29]. This association could be due to hospitality problem that may lead to dissatisfaction and reduce the likelihood of healthcare-seeking behavior and pushes them to traditional uvulectomy.
Didn't get cured by pharmacologic treatment was another factor pointed out by this study. Among the respondents who subject their child to uvula cutting 107 (16.9%) claimed that didn't get cured by pharmacologic treatment was the reason to practice traditional uvulectomy. Adjusting other factors, caregivers who claimed didn't get cured by pharmacologic treatment practices uvula cutting traditionally on their children 3.918 times than caregivers not claimed didn't get cured by pharmacologic treatment. This was in line and lower than the study carried out in Debre Birhan Town in which 50.5% claimed no cure with modern medicine [15].
As there were few studies conducted on traditional uvulectomy, this study might have an input for further research and will be used as a baseline data. It might also imply child health care by identifying the gaps it helps to reduce child morbidity and to improve quality of care.

Limitations
Even though the study conducted is community-based than institution-based to have a more representative prevalence of traditional uvulectomy, data obtained from the study participants through self-report were not cross-checked with their actual practices on the ground and clinical observation of the throat. In addition, the study didn't include a qualitative method as a result factor associated with traditional uvulectomy other than those factors described in the literature may not be addressed.

Conclusion
The prevalence of uvula cutting was found to be high (since traditional uvulectomy is forbidden and there is a national plan to eradicate it by 2025). The factors associated with traditional uvulectomy were lack of information about traditional uvula cutting and related issues, perceived as uvula causes illness, future intention or will perform traditional uvula cutting, perceived as traditional uvulectomy should not be eradicated (it is effective), saw the previous good result, health personnel hospitality problem and did not get cured by pharmacologic treatment. Better to create further awareness to the community at large and set controlling mechanisms to the health care delivery system.